AUTHORIZATION TO RELEASE PERSONAL HEALTH INFORMATION*
PATIENT’S NAME:_________________________________________ BIRTH DATE:___________________
I, ________________________________________________________________, residing at
_______________________________________________________, hereby give my consent to Kristi DuCote dba Kristi DuCote, MA, LPC, LCDC to release and receive personal health information contained in my Clinical Record regarding:
Mental health: _____ other: ____________________________
Medical history: _____ ___________________________________
Family history: _____
to/from:
Recipient/Provider of Confidential Info: _________________________________________________
Relationship to Patient: _________________________________________________________________
Phone Number(s): ____________________________________ Fax: _____________________________
Address: _______________________________________________________________________________
Recipient/Provider of Confidential Info: _________________________________________________
Relationship to Patient: _________________________________________________________________
Phone Number(s): _____________________________________ Fax: ____________________________
Address: _______________________________________________________________________________
for the purpose of (“continuity of care” if left blank):
______________________________________________________________________________________ .
I understand that this is valid until (indefinite if left blank) _______________, that I may with-
draw my consent at any time, and that I have a right to receive a copy of this authoriza-
tion form. I also understand that the information being disclosed pursuant to this authoriza-
tion may be subject to re-disclosure by the recipient, and may no longer be protected by
this privacy rule.
_____________________________________________ _______________
Patient Signature Date
* Compliant with the Health Insurance Portability and Accountability Act (HIPAA).
Kristi DuCote, MA, LPC, LCDC469.688.1787
101 S. Fannin St., Ste. 105, Rockwall, TX 75087
